XXX HEALTHCARE
POLICY/PROCEDURE TITLE:
CENTER FOR TRANSPLANTATION
Anticoagulation Protocol
DISTRIBUTE TO:
[ ] ADMINISTRATIVE
RELATED TO:
Effective Date:
[ X ] Patient Care
[ X ] TJC
[ ] Nursing Practice
[ ] Title 22
[ ] Med Ctr Policy (MCP) Stds
[ ] QA
VAD Patient
[X] CLINICAL
PAGE 1 OF 3
Reviewed or Revised: 10/1/2010
Unit/Department of Origin: Center for Transplantation – Heart
[ ] Other
[ ] CMS
[ ] UNOS
Transplant and VAD program
Other Approval:
Policy/Procedure
Committee Approval:
I. PURPOSE
To provide guidelines for the management of patients with immediate or prior history of Ventricular
Assist Device (VAD) placement.
II. INDICATIONS
Patient with anticoagulant/antiplatelet therapy post-VAD (HMII- BTT or DT & TAH) placement.
III. TREATMENT GUIDELINES
Heartmate II
The HeartMate II has unique anticoagulant properties, including acquired von Willebrand disease and
proteolytic cleaving, which affects how anticoagulation is managed.
1. Lab Data
a. CBC stat on arrival to ICU; then every 6 hours x24 hours; then daily while in ICU
b. PT,PTT, INR stat on arrival to ICU; then every 6 hours x24 hours; then daily while in
ICU
c. TEG (thromboelastogram), Bleeding times, Platelet aggregation, and other coag labs will
be ordered on an as needed basis
2. Medications Guidelines
Timing
Prior to leaving OR
Action
Completely reverse the anticoagulation
Immediate postoperative
period
Generally, no action.
Patients with atrial fibrillation, history of LVA or LA thrombus, or low
LVAD flow should be treated with anticoagulants (heparin)
Once patient medically
stable (Day 2 to 5)
Once there is no bleeding and the chest tubes are out:
Begin Warfarin - INR target range 1.5 to 2.0 unless another indication for
Coagulation exists.
Begin aspirin at a dose of 81 to 325 mg daily.
Maintain on aspirin and Warfarin. In patients with high risk of bleeding,
Warfarin may be held
Duration of support
TAH (Total Artificial Heart)
After TAH implantation, a hypercoagulable states is expressed that is dependent on pump design and
patient characteristics. Counterbalancing this multifactorial hypercoagulable condition requires an
individualized thromboprophylaxis regimen consisting of anticoagulants in combination with
antiplatelet therapy.
1. Labs
a. CBC stat on arrival to ICU; then every 6 hours x24 hours; then daily while in ICU
b. PT,PTT, INR stat on arrival to ICU; then every 6 hours x24 hours; then daily while in
ICU
c. Fibrinogen daily as needed
d. Thrombo Elastogram (TEG) daily as needed
e. Bleeding Time daily as needed
f. Platelet Aggregation as needed
g. Antithrombin III as needed
h. Pre-Albumin (target weekly but as needed)
2. Medications
a. Heparin; start 2-5 units/kg/hr beginning POD 1-3 based on CT drainage (CT drainage
<30ml/hr x4 hours)
i. Goal: Titrate heparin dose to maintain normocoaguability by TEG w/o
heparinase
b. Warfarin; start 2.5-5mg/day beginning POD 7-14 and following recovery of hepatic and
renal function and improvement in nutritional status
i. Goal: titrate dose to maintain normocoaguability by TEG
ii. Overlap heparin until patient is normocoaguability by TEG w/o heparinase x2
days
c. Aspirin; start 40-81 mg/day POD 1-3 based on plt count and CT drainage
i. Goal: per therapeutic bleeding time and platelet aggregation study
d. Dipyridamole; start 75-100mg q8hours post operatively
VAD Patient Anticoagulation Protocol 10-2010
i. Goal: increase dose by 100mg every 6 – 8 hours for platelet increase by 100,000;
do not exceed 300mg every 6 hours or 400mg every 8 hours
e. Pentoxifylline; start 200-400mg every 8 hours post operatively
i. Monitor for nausea/vomiting; decrease dose if necessary based on side effects
f.
Aggrenox may be substituted for Aspirin and Persantin for long term anticoagulation
therapy
Reviewed and Approved by:
Date
Executive Director, Thoracic Organ Transplant Programs
Date
Surgical Director, Heart Transplant & VAD Program
.
Medical Director, Heart Transplant & VAD Program
Date
Date
Administrative Director, Center for Transplantation
VAD Patient Anticoagulation Protocol 10-2010